IN THIS ISSUE. Executive Communication: Southeastern RACE Region. Regional EMS Spotlight: Brunswick EMS

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1 STEMI news NHRMC Heart Center Update on STEMI Systems of Care in Southeastern North Carolina SPRING 2012 WELCOME to the inaugural issue of the New Hanover Regional Medical Center STEMI Newsletter. New Hanover Regional Medical Center, in collaboration with its various receiving facilities and EMS providers, focuses on providing southeastern North Carolina with excellent care for STEMI patients. This newsletter provides valuable information on the current STEMI system of care at NHRMC and any new updates to STEMI patient care across the region. Each issue of STEMI News will share success stories, case studies, and other areas of interest related to STEMI patient care. A successful STEMI system with excellent patient outcomes depends on collaboration with all providers and effective communication. We at NHRMC hope this newsletter serves as one method to increase communication while further improving our system of care. IN THIS ISSUE Executive Communication: Southeastern RACE Region Regional EMS Spotlight: Brunswick EMS Clinical/Best Practice Update: Fibrinolytics Think Tnkase (Tenecteplase) Heart Savers November-December

2 EXECUTIVE COMMUNICATION Southeastern RACE Region By Claire C. Corbett, MMS, NREMT-P, AMI and Stroke Programs Manager, New Hanover Regional Medical Center The southeastern STEMI region is a complex and multidimensional system that includes seven counties with nine referral (non-pci) hospitals, one PCI center, seven EMS agencies, one critical care transport service and approximately 280 STEMI patients per year. Hundreds of physicians and healthcare providers work each day to ensure STEMI patients receive the care they need. The southeastern STEMI system began in early 2007 with the guidance of the door-to-balloon (D2B) program. NHRMC developed the Code STEMI response to decrease D2B times for STEMI patients. This included creating protocols and developing a streamlined multi-disciplinary response. The Code STEMI team was created to review all STEMI cases and focus on continual process improvement. In early 2008, NHRMC began participating in the RACE (Reperfusion of Acute MIs in Carolina Emergency Departments) program. NHRMC became one of the RACE PCI (Percutaneous Coronary Intervention) centers in the state and in doing so had to meet specific quality standards (see box below). The two primary goals of the RACE project are to increase the rate of reperfusion, ensuring RACE PCI CENTER REQUIREMENTS 1. Cardiac Catheterization Lab operational in 30 minutes, 24/7 2. One-call activation system 3. Onsite backup surgery 4. Accept all STEMI patients regardless of bed availability 5. Ongoing data monitoring and feedback 6. STEMI team with a leader and support of hospital administration 7. Goal of improving care regardless of hospital affiliation all eligible STEMI patients receive therapy by either thrombolytic therapy or primary PCI (ppci); and to increase the speed that reperfusion therapy is received. According to the 2008 ACC/AHA guidelines, patients treated with ppci should receive PCI within 90 minutes of first medical contact, and patients receiving thrombolytic therapy should receive thrombolytics within 30 minutes of entering the ED door. 1 To meet these goals, NHRMC began developing treatment and transfer strategies for patients throughout the region. Each area evaluated resources available to transfer patients as well as distance to the PCI Center (NHRMC). EMS STRATEGY Most EMS agencies in the region adopted a bypass strategy in which patients identified with STEMI in the field were transferred directly to NHRMC. This strategy was made successful by the implementation of pre-hospital activation of the cardiac catheterization lab. In this process the STEMI team is activated prior to the patient s arrival at the hospital. This allows for the mobilization of the cardiologist and catheterization team while the patient is en route to the hospital. Each year, pre-hospital notification saves approximately 35 minutes in treatment time in our region. REFERRAL HOSPITAL STRATEGY Most hospitals in the region initially adopted the mixed strategy, in which patients were transferred for ppci if transportation was readily available or treated with thrombolytic therapy if delay in transfer was likely. After a year, data revealed that the mixed strategy essentially meant not having a strategy, as each patient was handled differently based on the circumstances. One of the core principals of systems of care for time-dependent emergencies is to have a plan in place. By following the mixed strategy, treatments weren t timely for either transfer for ppci or administering thrombolytics. 2 NHRMC Heart Center STEMI NEWS Spring 2012

3 NHRMC HEART CENTER Zone 1: Cape Fear Brunswick Dosher Pender Zone 2: Columbus Naval Bladen Onslow Duplin Referral Hospital ZONE Plan Southeastern RACE Region Zone 2 Zone 1 In 2009, the region moved from the mixed strategy to the ZONE Plan. The ZONE Plan divided hospitals in the region into two zones Zone 1 for hospitals within 35 miles of NHRMC that would adopt a ppci strategy, and Zone 2 for hospitals more than 35 miles from NHRMC that would adopt a thrombolytic and transfer strategy. Most EMS agencies continued transferring STEMI patients identified in the field directly to NHRMC. The key to success with the ZONE Plan is following predetermined, standardized protocols that allow patients to be treated within the recommended guideline times. Significant decrease in treatment times have been documented since implementing the ZONE Plan. SOUTHEASTERN STEMI SYSTEM TODAY Currently STEMI patients present in our region in one of two ways, either by walk-in to the ED or by EMS transfer. STEMI patients identified by EMS as having a significant drive time to NHRMC, may be transferred by Airlink helicopter. Use of Airlink has been known to cut more than 30 minutes in transfer time, equal to a decrease in mortality by one full percentage point. 1 NHRMC s STEMI team reviews all of its STEMI cases to ensure proper guideline adherence and the delivery of optimal care. The program is predicated on continual attention to and focus on process improvement. In 2011, NHRMC received a Bronze Level Award from the American Heart Association s Mission Lifeline program. The award was granted for having met specific STEMI protocol standards, including achieving a 75% rate of direct presenters who received first contact-to-balloon time in less than 90 minutes for 90 consecutive days. 1 Antman, E.M., et al 2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients with ST-Elevation Myocardial Infarction. Journal of the American College of Cardiology p Rathore, S.S. et ala, Association of door-to-balloon time and mortality in patients admitted to hospital with SE elevation myocardial infarction: national cohort study British Medical Journal 2009, May SE STEMI System GLOSSARY OF TERMS EMS Walk-in Non-PCI Transfer for ppci Center Zone 1 EMS RACE STEMI Non-PCI Thrombolytic Center Zone 2 Walk-in PCI Heart Center NHRMC EMS EMS Walk-in Airlink Code STEMI PCI: Percutaneous Coronary Intervention PCI Hospital: capable of performing PCI 24/7 Non PCI Hospital: hospital that transfers STEMI patients to a PCI Hospital STEMI: ST Elevation Myocardial Infarction D2B: Door to Balloon RACE: Reperfusion of Acute Myocardial Infarctions in Carolina Emergency Departments ACC/AHA: American College of Cardiology/ American Heart Association NHRMC Heart Center STEMI NEWS Spring

4 REGIONAL EMS SPOTLIGHT Nick Jarman, EMT-P, BS Operations Supervisor/Quality Improvement for Brunswick Emergency Medical Services 1 Briefly describe your EMS agency: As the lead EMS agency in Brunswick County, Brunswick Emergency Medical Services (BEMS) operates nine paramedic units and one Quick Response Vehicle (QRV) supervisor. Our full-time staff includes 52 paramedics, 12 EMT-Intermediates, one EMT-Basic and 38 part-time employees. Additionally, Leland Fire/Rescue and Bald Head Island each operates one paramedic unit. Brunswick County EMS serves a population of just over 107,000 persons and is responsible for an area covering 855 square miles. From 2000 to 2010, Brunswick County experienced a 49% increase in population, making it the 37th fastest growing county in the U.S. at that time. As a retirement destination, Brunswick County has a large percentage of residents 65 years of age or older (20.6%), compared with the statewide average of 12.7%. Brunswick County s beaches and opportunities for outdoor recreation attract a large number of visitors each year causing a significant surge in population during summer months. The beaches, located on barrier islands, pose some significant access challenges, with Bald Head Island accessible only by passenger ferry. We are fortunate to have NHRMC s AirLink as a resource to serve these areas. 2 What is BEMS STEMI strategy/transfer plan? Our strategy for STEMI patients is rapid transport direct to a PCI facility. 3 What are some of the barriers you have had to overcome to optimize your STEMI protocol? Initially, there were some concerns about bypassing closer hospitals when transporting very sick patients 30 to 45 minutes further to a PCI facility. We quickly accepted that taking patients to the correct hospital rather than the closest hospital was the best way to get patients the treatment they needed. 4 How do you help unify a large and diverse county with multiple agencies and hospitals? We are fortunate to have a great medical director, Bill Sharrod, MD, who truly believes it is important to get the patient to the right hospital the first time. From the beginning, both Brunswick Novant Medical Center and Dosher Memorial Hospital have been champions of EMS transporting STEMI patients directly to PCI facilities. We are fortunate to have an active first responder system and volunteer rescue squads covering much of the county. They realize the importance of rapid transport of STEMI patients directly to a PCI facility. They help with rapid management and loading of patients, often providing a second or third set of hands in the back of the ambulance. They are a crucial component of our STEMI system. 5 Do you think transfer to the primary PCI center is obtainable within guideline treatment times? Yes, without a doubt! Even with some long transport times, we are still managing to achieve our goal of FMC to balloon in 90 minutes or less. 6 How do you encourage process improvement? How do you handle remediation? Crews love obtaining STEMI feedback. STEMI feedback is sent out to everyone involved in a call as soon as it is received. We use the feedback to analyze each call and look for opportunities for improvement. Remediation is handled on a non-punitive basis. This allows for a much more open exchange of information and helps promote learning. 4 NHRMC Heart Center STEMI NEWS Spring 2012

5 NHRMC HEART CENTER 7 Some agencies are pushing for on-scene arrival to EKG obtained in five minutes. Do you think this is beneficial and obtainable? It is absolutely obtainable and is very beneficial. How else can you expect to recognize a STEMI without a rapid EKG? It s only once a STEMI is recognized that the urgency of rapid transport becomes apparent. Obtaining a 12 lead EKG in five minutes is demanding, but it can be achieved through teamwork and repetition. 8 How have you worked with the 911 center to streamline rapid dispatch for inter-facility transfer for STEMIs? NHRMC TRANSFER CENTER The Regional Communications Center is a consolidated, regional transfer and dispatch center located at NHRMC s Cape Fear Hospital. This team manages the transfer of patients from outlying hospitals requiring the specialty services at NHRMC. Regional Communications additionally coordinates all requests for launch of AirLink and dispatches all transports performed by PCTS and VitaLink. Annually, more than 9,000 patient transfers are facilitated. As part of the Regional Communications Center, the NHRMC Transfer Center helps facilitate the transfer of patients to and from New Hanover Regional Medical Center. Transfer Center staff members are available 24 hours a day to allow physicians from outlying hospitals to contact a centralized call center and quickly be connected with an oncall physician from the appropriate department at NHRMC. Our transfer team stands ready to help. Call For STEMI, use the STEMI Hotline: 877.NHSTEMI ( ) This is perhaps the single greatest change that has allowed us to achieve faster reperfusion times for STEMI transfers. Our 911 dispatchers treat a STEMI transfer with the same priority of any other 911 call. Using AVL (Automatic Vehicle Locator), they dispatch the closest ambulance to respond emergency traffic to the referring hospital. NHRMC Heart Center STEMI NEWS Spring

6 CLINICAL/BEST PRACTICE UPDATE Fibrinolytics Think Tnkase (Tenecteplase) By Mary Beth Bobek, PharmD and David Weaver, MD, and Zack Horning, PharmD (Candidate) WHO: All STEMI patients in Zone 2 hospitals who are eligible for reperfusion therapy should be treated with fibrinolytic therapy (aka thrombolytics). The AHA/ACC guidelines recommend that all STEMI patients presenting with symptoms for less than 12 hours and ST elevation be treated with thrombolytic therapy if primary PCI cannot be performed within 90 minutes of first medical contact. 1 Be sure to perform a quick check of contraindications prior to initiating fibrinolytic therapy. Absolute contraindications to thrombolytic therapy include a prior intracranial hemorrhage, known intracranial neoplasm, ischemic stroke within three months, suspected aortic dissection, bleeding or known bleeding diathesis, or significant head or facial trauma within three months. Relative contraindications include poorly controlled hypertension (SBP > 180 mm Hg), ischemic stroke more than three months ago, dementia or intracranial pathology, prolonged CPR > 10 minutes or major surgery within the last three weeks, recent internal bleeding (within two to four weeks), a non-compressible vascular puncture, or the use of warfarin or other oral anticoagulation. If questions arise, the case should be reviewed with the interventional cardiologist on call. WHEN: The AHA/ACC recommended goal for fibrinolytic therapy is a door-to-needle time within 30 minutes of presentation. Performing fibrinolysis within the first 30 minutes of medical contact has shown to improve outcomes for STEMI patients. Timely fibrinolysis (door-to-needle 30 minutes) versus delayed fibrinolysis (door-to-needle >30 minutes) was associated with a statistically significant reduction in risk of a composite outcome of death, shock or stroke. 2 The decision to initiate fibrinolysis must be made immediately. Patients who are treated with fibrinolytic therapy still require rapid transfer, evaluation by cardiology and potential cardiac catheterization. WHAT: TNKase (tenecteplase) is the preferred fibrinolytic agent in the SE STEMI region. Tenecteplase was shown to be equivalent to alteplase (tpa) in clinical outcomes but had a lower bleeding risk (ARR -12.8%). 3 Also, tenecteplase s single bolus administration technique provides a practical advantage other thrombolytic agents such as reteplase or alteplase. Frequently, the second dose of reteplase can be missed during transfer. Tenecteplase also avoids the use of IV infusion pumps. The IV bolus should be administered over five seconds (not to exceed 50 mg). The vial of TNKase should be mixed with the enclosed 10 ml sterile water. DO NOT SHAKE THE VIAL. TNKase is incompatible with dextrose containing solutions (flush line with saline prior to and after administration). This requires a second nurse verification prior to administration. Monitor for signs and symptoms of bleeding and any arrhythmias. HOW: Pt Weight (kg) TNKase (mg) Volume TNK to be given (ml) Less than Greater than or equal to DON T FORGET! Patients that are treated with fibrinolysis also need other important adjuncts to this treatment. The administration of IV heparin, aspirin and clopidogrel, according to the treatment algorithms, helps preserve infarct vessel patency after the use of fibrinolytics. 6 NHRMC Heart Center STEMI NEWS Spring 2012

7 NHRMC HEART CENTER WHY: Reperfusion therapy saves lives! For hospitals unable to meet the first medical contact-to-balloon < 90 minutes for primary PCI, fibrinolytic therapy is the life-saving therapy that can be applied to the majority of patients. By choosing fibrinolytic therapy, healthcare providers can save lives, improve outcomes after MI and prevent long-term complications. 1 Antman E et. at Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction. J Am Coll Cardiol 2008; 51: Glickman S et al. Delays in fibrinolysis as primary reperfusion therapy for acute ST-segment elevation myocardial infarction. American Heart Journal 2010; 159,6: Van De Werf F et al. Single-bolus tenecteplase compared with front-loaded alteplase in acute myocardial infarction: the ASSENT-2 double-blind randomized trial. Lancet 1999; 354: Reg Comm: Dispatch EMS or Airlink Goals: EKG < 10 Minutes Door-in Door-out < 30 Minutes 1 st Door-to-Balloon < 90 Minutes Zone 2 STEMI Protocol: Transfer for PPCI Chest Pain or Equivalent: EKG within 10 minutes Meets STEMI criteria? Yes NHSTEMI EMS or Airlink Available? Yes Administer: ASA (325 mg PO) Heparin Bolus (60 IU/Kg) Clopidogrel (600 mg PO) NTG SL or Paste PRN Avoid Nitro Drip Prepare for Transfer No No STOP Administer Lytic: Door to Lytic < 30 minutes ASA (325 mg PO) Heparin Bolus (60 IU/Kg, max dose 4,000 IU) Clopidogrel (300 mg PO, If Age > 75 administer 75 mg PO) Avoid Nitro Drip Prepare for Transfer COMMITMENT TO QUALITY Two prestigious awards recently bestowed upon New Hanover Regional Medical Center by the American Heart Association and the American College of Cardiology affirm NHRMC s commitment to providing exceptional care to heart attack patients. The American College of Cardiology Foundation s NCDR Action Registry-GWTG Gold Performance Achievement Award recognizes NHRMC s success in implementing higher standards of care for heart attack patients. NHRMC is one of only 167 hospitals in the nation to receive this recognition. NHRMC also received the American Heart Association s Mission: Lifeline Bronze Quality Achievement Award for its success in implementing higher standards of care for heart attack patients. The national benchmark for getting STEMI patients to life-saving cardiac intervention is 90 minutes; the average time at NHRMC s Heart Center is 44 minutes. For more information, visit and NHRMC Heart Center STEMI NEWS Spring

8 HEART SAVERS November-December Brunswick Novant Medical Center on 11/1/11: 1st D2B = 75 minutes Transported by Brunswick EMS New Hanover Regional EMS on 11/15/11: E2B = 42 minutes Transported by New Hanover Regional EMS Columbus Regional Healthcare System on 12/15/11: D2L = 19 minutes Transported by Airlink Pender EMS on 10/13/11: E2B = 67 minutes Transported by Pender EMS D2L (door to thrombolytic) 1st D2B (door 1 to balloon time) E2B (EMS arrival on scene to balloon time) 2131 S. 17th St. Wilmington, NC